Healthcare Lift and Tint Consent Form

HEALTHCARE LIFT AND TINT CONSENT FORM

Patient Information

Patient Name:

Date of Birth:     Gender:

Emergency Contact

Insurance Information (if applicable)

Procedure Description

Procedure: Lift and Tint of Eyelashes and/or Eyebrows. This procedure involves application of chemical solutions to elevate and/or curl eyelashes or eyebrows (lift) and application of pigment to darken lashes or brows (tint). The practitioner will apply protective barriers and monitor the process to reduce chemical exposure to skin and eyes.

Medical History

Risks, Benefits and Alternatives

I understand that the anticipated benefit of the lift and tint procedure is improved appearance of lashes and/or brows. Reasonable results are expected but not guaranteed.

Known risks and potential complications include, but are not limited to: temporary or prolonged eye irritation, redness, swelling, allergic reaction, eye surface injury from solution contact, uneven result, breakage or damage to lashes or brows, skin discoloration, infection, and need for additional treatments. Severe complications are rare but may require medical treatment.

Reasonable alternatives include not undergoing the procedure, using temporary cosmetics, or selecting alternative cosmetic procedures. I have had the opportunity to ask questions about risks, benefits and alternatives and acknowledge they have been explained to my satisfaction.

I acknowledge that I have been informed of the risks, benefits, and alternatives and that my questions have been answered.

Consent and Authorization

By signing below I voluntarily consent to the performance of the lift and tint procedure described above by the practitioner and clinic staff. I authorize the practitioner to perform such additional procedures as are necessary or advisable in the practitioner's professional judgment to address unforeseen conditions encountered during the procedure.

I consent to the use of topical preparations, perming and tinting solutions, and other commonly used cosmetic agents. I understand that reactions to these products can occur and that if a serious reaction develops, I will immediately notify the practitioner and seek appropriate medical care.

I authorize the taking and use of clinical photographs, video, or digital images for medical documentation, treatment planning, and internal quality assurance. I understand images may be used for training or education unless I decline below.

I consent to the use of my clinical photographs for medical documentation and internal uses.

I decline external or public use of my photographs (educational use within the clinic only).

I understand that I may withdraw my consent at any time prior to the procedure by notifying the practitioner; however, withdrawal of consent will not affect any actions taken prior to such withdrawal based on my prior consent.

I certify that I have provided a complete and accurate medical history and that I will inform the practitioner of any changes in my medical condition, medications, or allergies prior to treatment. I understand that failure to disclose accurate information may increase the risk of complications.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or provided the clinic's notice of privacy practices describing how my protected health information may be used and disclosed. I authorize release of my health information for purposes of treatment, payment and healthcare operations as necessary for the performance of this procedure.

I acknowledge receipt of the privacy practices and authorize use of my protected health information as described above.

Emergency Treatment

In the event of an emergency or an unforeseen complication requiring immediate medical attention, I authorize the practitioner to provide or arrange for emergency treatment and to share relevant information with emergency medical personnel.

I consent to emergency treatment as described above.

Financial and Aftercare Acknowledgment

I understand the estimated cost of the procedure has been explained and that payment policies have been presented. I agree to follow post-procedure care instructions and understand that failure to follow aftercare may adversely affect results and increase complications.

By signing below I certify that I have read and fully understand this consent form, that the procedure, risks, benefits and alternatives have been explained to me, and that all of my questions have been answered to my satisfaction. I accept responsibility for disclosing accurate medical history and for following all aftercare instructions.

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